Nurse Practitioners in Business

About

Nurse Practitioner Business Owners blog (NPBusiness.ORG) is an idea that was born out the need and frustration for Nurse Practitioners in private, independent practice to be able to connect, share resources, offer support, and learn from one another. It goes beyond that day to day support we give and receive from one another around our professional practice…this goes into the business of being a NP.

NPs who have their own practices are breaking the mold for NPs in general as most are still in employed situations (out of preference or necessity). There are also NPs who have broken the “private practice mold” and are working in and outside areas of health care that are new and exciting. NPs have businesses in the educational field, legal field, insurance field, anti-aging field, retail and more.

It is the goal of this site to look at all areas of business that NPs are involved in. To do so…it requires that input and assistance of many NPs…and fortunately, several NPs in practice have already agreed to participate.

NPBusiness.ORG will is new and will continue to grow with the needs of Nurse Practitioners. You are encouraged to participate and can do so in one of many ways:

Leave a comment on the blog

Contribute a written piece – perhaps an article, resources or practice regulations in your location, etc. Some ideas for articles of interest may include issues around billing, insurance companies, finding the right malpractice policy, hiring staff, outfitting an office, business insurance, book-keeping, taxes, legal assistance and business structure just to name a few.

Answer questions and offer support to those needing assistance.

I am often asked how someone can work with me. You’ll find updated information on suggestions when you visit our Work with Barbara page.

To contact me or to leave a general comment, concern or question, please feel free to use the contact me forms you’ll find around the site.

Affiliate Disclosure:

Please note that I may be an affiliate for some (not all) of the products and services I recommend in this blog. What this means is if you purchase a product or service through one of my affiliate links, I may receive a commission from the seller. This does not affect your purchase price at all. What this does is it helps support this blog so that we may continue publishing and making this content available to you free of charge. We only use affiliate links on products and services we feel we can endorse. As always, it’s up to you to always do your own due diligence before your purchase anything.

Comments 63

I stopped by after reading your nice comment on my blog. What a great site you have here! While I’m not working as an independent (quite yet! new grad), I will eventually have a go at it someday. Meanwhile, I supplement my student loans with adsense ads on my regular blog site. I will definitely be back to find out all the great tidbits so when I’ll be ready, I will really be ready!

Well. I have found my way here and it looks great. Congratulations!! I have given a PhD program a try, but it is not meeting my expectations or i was unclear as to what I wanted from it. I am now being offerred a chance of a lifetime-to start in a new integrative med clinic where i can build my own practice.

I don’t have funds to go in without some financial backing so I have to develop a plan for the MD on how to pay me intil I can afford to be independent of him. In my state, i need an MD to practice, so I will always be tied to him at this clinic. I have the books that are recommended, but it will take time to go thru them.

I am hoping someone here has some advice and sample contracts. has anyone taken out a business loan to get started?

I am open to any suggestions. I hope to blog on this process as i go along to help others as they come along.
Paula

Welcome over here! Barbara has done a great job. I am on a shoe string. No business loans. However as far as supplies for a practice, e-surg gives you a line of credit. Regarding contracts, for working with doctors, Carolyn Buppert has a book on Productivity based practice, and she also has a sample independent contractor contract in her original book. The website http://www.nnba.net also has books on contracts. But I am working part time at another job, and being single, am just really hoping my practice will at least see 3-4 patients a day to start which will help me pay the bills. I do not plan to open until mid June. email off line if you wish because are you still working for the integrative clinic? Carla email: carla_rayn at yahoo.com

Paula, I shopped at a lot of 2nd chance stores for some things and a lot of my office furniture is used. Fortunately the physicians that I have a collaborative relationship with did not request a fee…. One of my nurse practitioner colleagues said that physicans in Mississippi may ask for 0 – $1000 per month… for being your collaboarative physician. You can find contracts on line…. Talk with your chamber of commerce also you may have to join… but for me it has been worth it…

Don’t stock pile anything until you start seeing a substantial amount of people… I have supplies just sitting on the shelf… and I am having to pay charge card every month for supplies I have yet to use…. HOpe this helps

Paula, I am currently in the process of trying to get a business loan. I realize that your posting was a few months ago, but I would love to hear if you have gotten a loan as of yet? Or how it is going? Any advice would be appreciated. I have been working with the SCORE counselors in this area. The biggest problem that I have run into is not having cash to put into the business. I have equity in my home, but the I was told I could not take it out of the equity in my home. I am however in the process of refinancing my home and plan to reapply with cash in hand.
I would appreciate any suggestions.
Thanks,
Sherry

Paula, I am about to open my own practice in AZ. it was an existing NP practice w/ very low overhead. I am in need of some help w/ gettin credentialing it seems overwhelming does anyone have any advise. I am hoping to open 2 days/wk in May and wouls like to start w/ cash and hopefully medicare until credentaling is approved. Any advice.

Credentialing is not a walk in the park, but once it’s done you should not have to revisit it often. I recommend contacting each insurance company you wish to accept and obtaining there contract for credentialing. Also, find out who your provider rep is for each payer. Most contracts are not too difficult, just tedious. You can always outsource and have a third party handle the contracts for you. Make sure you do a CAQH profile, because most payers will work from that and all you have to do is sign the contracts.

Just found this site and am grateful for its existence. Still working on my NP in gerontology, in addition to certs in LNC, and Patient advocacy. Dream is to have a practice with a couple of talented practitioners. I will be accessing this site often, while on my way.
Thank you, Laurie

Barbara and others: just found this site, thank you for all of your comments and advice. Would love to connect up with a mentor who has started an independent practice. I have had other businesses so some of this is not new but the billing aspect could obviously make or break. So what is the FIRST thing to do as to billing. And as for malpractice, does anyone have some contact information. I am in Indiana so assuming I need a collobarator. I am working on a business plan and timeline right now.

hello I am a family nurse practitioner, interested in starting my own practice. I want to start slow by seeing my own patients on saturdays only until I built up my clientele. My father is an internist with his own practice. He has agreed to let me use is office and equipment on the weekends. My question in how do I go about getting credentialed and reimbursed? I am currently credentialed with my current employer (a community health organization). Do I need seperate credentialing for my own practice? Any information/advice you can provide would be greatly appreciated. I practice in Tennessee

You will need to establish your business as an entity unto itself. Once you do that, you’ll need a separate tax ID number (EIN) and an NPI for that business (you also keep your own NPI). Then you will need to get credentialed. Some will allow you to just send them the new numbers, others will require you to start the credentialing process all over.

Hello, I am at the very begining of the decision to open a NP run pediatric clinic for underserved population in my hometown. I hope to accept CMS and other insurance although, I’m not sure how to go about this all. In my area, there are many pediatricians accepting all other insurance except Medicaid. There are so many families in this area that are in need of care. I guess my first question is: 1. Do I just need a LLC and business and tax number to get the ball rolling? I’m lucky to have a friend that will handle all the credentialing for me and 2. Is this really feasible? Thanks so much, an advise would be appreciated.

One of the reasons that many practices are not accepting Medicaid is due to low reimbursements. You will really need to look closely at your overhead costs and estimate your reimbursements to see if this is a feasible plan for you. You do need to create a business (LLC or otherwise) as well as get a tax ID number.

Do a search on this blog, as well as the archives of ProgressNotes @ http://www.NursePractitionerBusinessOwner.com. We have discussed this many time. Alternatively, watch for the announcement of our course on starting up your practice, we plan on presenting it again this fall (just trying to schedule now).

Hi, i am a certified adult NP in California and seriously considering to start my own medical spa business for botox, fillers, laser treatments, etc. I am going to use a room in a physician’s office and will be paying him on a patient flow basis, maybe a percentage. He is going to be my contracted mdical director/collaborating physician. My 1st question is that I want to be the sole owner of the practice, is this legal in california or the collaboarting MD has to have a share of the business? Secondly, how much do you think i should pay him per day for using his office and how much per patient. i will start with 1-2 days/ week however until i build up my business and client flow. Thank you.

The way that I understand California is that as an NP, you cannot own 100% of a medical corporation. A physician must own the majority, and the most you can own if 49%. [California Business and Professions Code: 13400-13410 (Moscone-Knox Professional Corporation Act).

You can own 100% of a “nursing corporation”, but it must use the term “nursing” or “nursing corporation” [California Business and Professions Code: Section 2775-2781 ].

You may want to check with a CA attorney. I understand that Melanie Belestra (also an NP) has worked with NPs to establish the proper corporate structure for CA, for the type of business you are planning, and finding a way for you to own 100%.

I am still wanting to start an independent practice; or do a buy out on the physician practice I now work at (a practice with a physician who will be retiring soon). We see many medicaid patients and many under served patients on the MD wise plans. On some of the other jobs I view on the internet there are school loan repayment incentives for certain areas for 2 year commitments of employment. Does anyone know how to check on grants or loans for buying out or possible way to get an incentive for school loan repayment if I look at buying out this practice? Or a way to qualify for the incentive for school loan repayment while continuing at this office.
I also have to comment on our recent postings of salaries survey done. NP’s were on average paid less than PA’s. I am very puzzled by this information and very disappointed in our reimbursement for (28 years of nursing experience) and so many years of patient care.

There are a lot of NP Practices in Maryland. The business structure you use will depend on your state laws (check with your secretary of state) and what kind of entity you need/choose. I have seen all forms of corporations being used – most commonly LLC and C-Corp.

In order to receive grants, you need to be a nonprofit corporation. In order to see about becoming eligible for NHSC loan repayment status, you will need to contact NHSC to see if you can qualify. You may need to become a non-profit for them as well, but again you’ll need to check their guidelines.

In terms of your “many” of low income/medicaid clients, you will need to look very carefully at the financially to determine if this practice is financially viable in the way you wish it to be. In many cases, practices need a good mix of payers to be financially sustainable.

I am a NP in Oregon which allows independent practice, including cosmetic procedures. I have completed training for Botox/filler injections and would like to set up a side business offering these services. Do you know what would be required to provide “Aesthetic Parties” in which I provide these services to clients in their homes or at a spa/salon?

I am a nursing student, graduating in May, and entering a nurse practitioner program in the Fall. I’m looking ahead already and have started to work on a business plan for my future nurse practitioner practice.

I’ve been researching reimbursement rates from Medicare and Medicaid (I am familier with the 85% rate of physicians’ fees), but I can’t seem to find a current average dollar amount from them or other insurance companies to put in my financial analysis section. Do you know where I could find this information or do you have any insight?

Congratulations on graduation! I think it’s smart for you to be keeping the idea of business in your mind as you move through your education. Things will begin to take on a very different look and feel.

In general, private insurance companies do not publish their rates as they are consider proprietary trade information. In fact, in most of our contracts, we are prohibited from sharing the information. I’m sure there are various reasons they feel this is necessary, one of which is that providers are paid variable amounts depending on if and how well they can negotiate their contracts.

Government payers do publish their rates. You can find Medicare, Medicaid, Champus, VA, and most Workers Comp program reimbursements online. In my experience, the published Labor and Industries/Workers Comp rates are close to the commercial reimbursement rates, but that can vary by state.

Hi. am getting old and want to bring in another practitioner into my solo practice. We have an S Corp as our business model. need to have some idea about joint practice agreements, tips on how to bring her onboard without either bankrupting me or making her/him work for slave wages. anyhelp would be appreciated. thanks. Betty

Great site you have here, I am a new grad ANP looking at going straight in to starting my own technology based primary care practice aimed at teens and college-aged students. I realize the importance of being sustainable and profitable however I view getting involved with insurance companies as jumping into a pool of paperwork and drama (had enough of the latter in nursing school). Instead, I am considering starting off at least as a pay per service option, skirting the insurance maze. Aside from all the other difficulties of starting a business, do you think an out-of-pocket service is a viable way to get one’s business started in the healthcare world?

And if there are any other new-graduate NP’s in the Nashville, TN area, definitely shoot me an email if your interested in collaborating!! wilsonjw03@yahoo.com

I do believe there is a place for direct pay practices…leaving insurance out of the picture all together. Lots of ways to achieve that. The problems with insurance for many people is that if they do have it, their have high deductibles. As we move forward with a mandate that everyone has insurance, I’m not sure that will change.

Starting a practice without getting involved in insurance is a great way to create a practice that is cost effective and sustainable. But…you need to do your homework first and get a plan in place.

I am a Family Practice NP in Utah, and am looking to start my own practice. I have a friend who owns her own business and would be willing to rent me out a room, and even refer me her patients as she is a psychologist dealing primarily with anxiety and depression. My question is, I looked to fill out the CAQH online, and it said that I needed a CAQH ID. How do I obtain that? I have an NPI number already, is that what it means?

The health plans you are credentiling with will give you a CAQH provider number so that you can get started with CAQH. So for example, if you are working with Cigna Healthcare, they will invite you to fill out the CAQH giving you an ID number. You only need one in order to get started. According to CAQH “If you have not received a CAQH Provider ID, please contact your health plan or hospital to confirm that they are participating.”

Your NPI number – both your personal and your business numbers are part of the required numbers you will need to fill out the credentialing application.

I am a MD NP who is starting my own practice, I am currently partnering with a physician but will be branching off on my own in a few months to a year. My biggest hurdle that I see is getting the clientele, do you have any suggestions as to how to get clients into my practice. I plan to rent from another NP or physician.

Hi I live in New York and have my own practice with a collaborating physician. I want to start doing botox and fillers injections but I’m not sure if it’s within my scope in NY. Do you have any information on this issue? Thank you

Hi…I am a independent NP opening my own business in Indiana. The biggest hurdle I have found is a collaborator. I have tons that are interested but they look into their medical Malpractice (medical protective or pro assurance) and they do not cover an independent NP. I have found a medical director policy that can work but it is an additional $3500.00-$7000.00 per year. Does anyone have any additional suggestions? I have friends that have opened their own practices and they and their collaborator assume since they have their own malpractice insurance that they are covered. If they dig deeper and if they named in a suit the collaborator can be called in but…their malpractice will not cover them. Any thoughts????

What a great resource. I am FNP in NC. I would like to open a private practice for headache patients. Currently working in a hospital owned practice I am credentialed for bottom. My family owns several dental practices I am hoping to try weekend hours at first until I can afford my own space. Do I start with the board of nursing to get info? I don’t know the first thing about owning my own business. Thanks!

First thing to do is figure out exactly what you want to do and start getting it on paper. Lots of homework to do. At the same time check with your BON to find out what rules they may/may not have. You will also want to check your state corporation rules as well. Lots of NPs in NC with their own practices.

Do you need a collaborative agreement if you get your DNP? Also, considering selling my aesthetic practice in Orange County California- doing very well but planning a relocation to Hawaii. All cash business and top of the line equipment! Hard work-good money!

I am looking at opening my own NP practice here in California. I read in an earlier post that this cannot be done with the NP as the primary owner (can only own 49%). Do you know if this information is still current? Also, this is quite a wonderful “find” for me….your website looks like it has a wealth of knowledge available if I do decide to go out on my own. Thank you for all your hard work getting a site like this up and running.

This is indeed a great resource! I am planning to go into private practice with another pediatrician (MD). We are putting equal amount of money as a start up capital. I understand that reimbursement for NP is less than the MD. My questions are:
How do we split the profit sharing?
How should I get paid since we will both see the same number of patients (I may be seeing more)
Thank you.

Profit sharing: you will need to determine percentages. Not all insurance companies will reimburse differently though most do. Your reimbursement will vary from company to company, and often year to year.

Bill under your own numbers and get paid on your own patients, and the physician would get paid on those he sees.

I am in Florida and have a small business where we offer facials, et….we are looking to hire an ARNP to run the injectable and laser business. Does there also have to be a medical director involved? The FL statutes seem rigid, but I do know of many many PA’s and NP’s doing cosmetic procedures without a doc.

Hello and thank you for this site. I am an OB/GYN NP and am currently enrolled in a dual FNP/AANP DNP program. I am searching for a preceptorship with either a board certified peds/family practice NP or MD in the Los Angeles area (preferably Burbank/Glendale/Los Feliz area), but am having a hard time finding someone. Does anyone have any ideas or can precept me for 180 hours over the next four months? Big thanks!!!!

Really a great resource! I am planning to go into private practice with another MD in PA. Do you know anyone who is in private practice? I have one NPI from my current employer. Do I have to have another NPI for private practice?

Many of us are in private practice. Read the startup sections for further assistance.

You have an individual NPI…that number is yours and follows you everywhere. You will also need to have a business NPI that you apply for after you have gotten your tax ID number and business license. You’ll need both numbers to bill.

Hello, I have been a FNP for 16 years and recently graduate with my DNP. I am very much interested in my own independent practice for 2014. I asking for a little guidance, so please direct my path to get started.

Hello, I am a nurse practitioner in WV and own my own practice, Anchor Medical, LLC. Prior to opening, I hired a company to to a feasibility study to determine how I could legally open a practice in WV. When the study was complete, it was determined that I could open a family practice and see patients as long as I had a collaborative agreement with a physician. This is what I did. The company I hired also helped with advice on the business license, waiver for the labs we would do, etc. Another company did my credentialing with insurance companies. I opened my practice on April 3rd 2014. After opening, I realized that to ask my collaborating physician to be available to me in a new practice (she has her own practice) without financially compensating her would not be fair. She and I discussed this, drew up a contract, and I hired her as a salaried employee. She is available to me anytime I call and comes to my office one day a week to see some patients that require evaluation by a physician. It was slow at first (very slow) but has since pickup and I have quite a few patients. Every insurance company I credentialed with new of this practice. Everything seemed to be going quite well. Until last week. I received an email forwarded to my from the WV Board of Nursing. An investigator from Highmark WV sent a letter to the Board essentially stating that I was in violation of the law in WV because it was not legal for me to hire a physician to practice in my clinic. The Board did sent this email to the Board of Medicine to see if they felt I had violated any law. Now I’m just waiting to hear if I still have a practice or not. A lawyer for the Board of Nursing does not feel I am violating any laws. But, as you can imagine, I am very upset by this allegation. The company that helped set up my practice said I should just wait and see what the Board of Medicine says. The Board of Nursing says that it will be up to the Board of Medicine to determine if they feel I have violated the law in WV and file a complaint against my license. I really am not sure I can afford an attorney right now or even if I need one. Do you have any advice for me regarding this?

This is a situation that is problematic for many. You must look at corporate rules and regulations as well as practice acts. In some of our states, NPs CANNOT “hire” a physician and yet we are forced to have collaborating agreements.

You may be able to get around this by using the physician as an independent contractor or consultant, ie, not as an employee.

That’s Ok. I have been very busy as well. To catch you up: I hired an attorney and he says I am not breaking any WV law. WV Medicaid had questions about my practice (they received anonymous complaints but wouldn’t say exactly what they were) which my attorney was able to answer apparently to their satisfaction. However, just today, I received a certified letter from Highmark BCBS. An investigator for Highmark has filed a formal complaint with the WV BON against my license. They allege that I am in violation of WV law since I have hired a physician (she is my collaborating physician). I am not a corporation or a PLLC. My company is an LLC. The only other NP owned practice that I know of is also an LLC. The person that filed the complaint is the same person that wrote the initial letter to my nursing board. So, I am back to square one. I will send this letter to my attorney on Monday. I am already several thousand dollars deep into this fight. I will continue to fight. It is interesting that the person who filed the complaint is the friend of the office manager of my previous employer. My attorney feels this is a personal vendetta. We were hoping it would not go this far. I believe this may set the stage for other NPs in my WV regardless of the outcome. If I win, it will open doors. If I lose, I fear it will close doors for NPs. Wish me luck! I will keep you up to date so that you will be able to share this with others.

1. An LLC is a corporation. You have the option of choosing how you are taxed (individual flow through or S Corp). But it’s still a corporation and subject to any rules and regulations that WV has for corporations.

2. In some states NPs are prohibited from “hiring” a physician (even though they are required to have a collaborator). California corporate laws even state that the physician has to own 51% of a medical practice. I’m sure your attorney and the BON has looked at that, but just in case…

3. Consider contacting AANP Government Affairs to see if you can get some pointers here. They have a section that deals specifically with states.

I realize that West Virginia (beautiful state btw) is rather restrictive in it’s practices and I’m sending you all the prayers and white light that this turns out in your favor. Please keep me posted.

I appreciate all of your positive energy…I ‘m going to need it. My attorney has asked for an extension from the BON but I haven’t heard anything yet. The extension will allow me to answer the BON after the hearing with Highmark on the 26th of this month. The law in WV is very vague when it comes to NPs owning their own practices and paying physicians to collaborate.

There is one statement in the law concerning the corporate practice of medicine in WV that may be my saving grace. It states the law is not intended for other licensed practitioners working within their scope of practice. So far, the Board of Medicine in WV has not weighed in on this matter (I’m almost afraid to say that). At this time, my collaborating physician has not heard anything.

Please continue to send me you positive energy. I will keep you posted on events as they unfold.

Thank you so much for all of the valuable information that you have offered so many. I am an FNP in CA and have a few questions:

1.) I am very interested in owing my own urgent care. Is there anyway that I can open up an urgent care under a nursing corporation?

2.) My wife is a psychologist and I am a nurse practitioner and we want to work together providing both psychological and medical services. She will be providing the therapy portion, and I will be providing the medication management portion of the treatment (with the collaboration of a psychiatrist). She is qualified to open up a psychological corporation, but will I still be able to provide medical services in addition to the psychiatric service all under one corporation? Or will I need to have a separate “nursing” corporation for the medical services that I intend to provide? We are trying to avoid having to form two separate corporations if this is at all possible.

3.) What do you suggest is a fair fee to pay for an independent contractor/collaborating physician that I consult with? Should I pay them per patient, if so, how much? Or a flat fee monthly/yearly?

4.) What types of procedures/services can I provide independently if I establish a nursing corporation?

California has very specific laws, and for some of this, you will need to find an attorney who is knowledgeable in these areas.

1. I am not sure that you and you wife will be able to be in the same corporate structure because you both hold different types of licenses. Check the corporate laws for CA.

2. My understanding of the practice act is that it’s dependent on the organization. So you could write a practice act for your company that allows you to do what you are trained to do. Obviously, you’d need your CP to agree.

3. “Fair fees” vary all over CA (not the same in SF as it is in Cresent City). Do a bit of research for your particular location. Take into account how much work your CP will need to do. Make sure you get any agreements in writing.

4. To my knowledge, what you can do within a nursing corp is not going to be much different than a medical practice, but again, check with an attorney on this. I do know you need to have in your title Nurse or Nursing.

Hi Barbara
I am a FNP and own my practice for about 5 years; I recently hired 2 part time NP’s and I am sure they eventually will want to open their own practice too. My question is how many miles from your current job can you open your own practice. Is there a legal paper that can be sign as an agreement that it would not happened in the same area?
Thank you
Liliana

Liliana, that is what is called a non-compete clause. In some states they are not enforceable, you would need to talk with an attorney in your area. In terms of practice restrictions – it’s usually spelled out in distance and time. If you choose to go this route, it would need to be reasonable. Restricting someone to practice in the city/town would be considered unreasonable.

Having a good relationship with these NPs and a good relationship with your patients is probably your best protection. Remember…patients can always leave and go elsewhere for care if they choose.